Suicide risk management in research on internet-based interventions for depression: A synthesis of the current state and recommendations for future research

Assessment of suicidality in trials of psychological interventions for depression: a meta-analysis

BACKGROUND

Psychological interventions that are efficacious as treatments for depression could indirectly affect suicide-related outcomes. We examined suicidal thoughts and behaviours as eligibility criteria, outcomes, and adverse events across trials of psychotherapy for depression.

METHODS

We used a publicly available meta-analytic database developed through systematic searches (updated as of May 1, 2023) to identify randomised controlled trials in which a psychological intervention for depression was compared with an inactive or non-specific control condition in adults with depression and in which any suicide-related outcomes were reported. We also identified studies in which suicide risk was an exclusion criterion. We excluded inpatient studies and trials of unguided digital interventions or collaborative care that included a psychological component. Pairs of reviewers worked independently to select studies and extract data. In a random-effects meta-analysis with robust variance estimation, we assessed the effect of the psychological intervention on suicide outcomes in trials in which suicide was explicitly assessed as an outcome with clinical scales with established psychometric properties. Risk of bias was assessed with the Cochrane risk-of-bias tool (version 2).

FINDINGS

Of the 469 randomised trials we identified in which a psychological intervention was compared with an inactive control in people with depression, 251 excluded people judged at risk of suicide. Any assessment of suicide was included in only 45 trials, 12 of which assessed suicidal ideation or risk as an outcome. These 12 trials included 3930 participants, 2795 (71%) of whom were female and 1135 (29%) of whom were male; data for age and ethnicity were not consistently reported. Psychological interventions for depression were associated with a small reduction in suicidal ideation and risk in 11 trials (one trial reported only follow-up data) after the intervention (standardised mean difference -0·31 [95% CI -0·60 to -0·03]) but not at follow-up (-0·49 [-1·31 to 0·32]). Suicide-related adverse events were reported in 25 trials, and suicide-related serious adverse events (eg, suicide attempts, deaths by suicide) were reported in 13 trials. Heterogeneity was substantial across all analyses, and prediction intervals crossed zero.

INTERPRETATION

Trials of psychological interventions for depression rarely report assessments of suicide. Psychological interventions might reduce suicidal ideation in patients with depression, but more randomised controlled trials are required to clarify this effect. Monitoring and reporting of suicide-related adverse events should be improved in trials of psychological interventions for depression, and future trials should incorporate outcomes related to suicidal thoughts or behaviours.

FUNDING

None.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

What to do when the unwanted happens? Negative event management in studies on internet- and mobile-based interventions for youths and adults with two case reports

Background

Despite severely burdened individuals, often being excluded from research studies on internet- and mobile-based interventions (IMIs), negative events (NEs) including suicidal thoughts and behaviors (STBs) can still occur during a trial. NEs require monitoring and adequate safety measures. However, study protocols frequently lack comprehensive descriptions of procedures for managing NEs.

Aims

This study aimed to illustrate the assessment, monitoring, and procedures for addressing NEs in two studies on IMIs in adults and youth using case reports, to identify strengths and weaknesses of the NE management approaches, and to derive key learnings and recommendations.

Methods

Two case reports were drawn from two distinct IMI studies. The first study, PSYCHOnlineTHERAPY, evaluates the combination of an IMI with on-site psychotherapy for anxiety and depressive disorders in adults (adult blended study). The second study evaluates a standalone, therapist-guided IMI for post-traumatic stress disorder (PTSD) in youth (youth standalone study). Potential NEs were predefined depending on the study sample. The case studies thoroughly document the systematic recording and ongoing monitoring of NEs through self-report and observer-based assessments during the interventions. The cases illustrate a variety of NE management strategies, including automated and personalized approaches, adapted to the specific nature and severity of the NEs. The NE management approaches are visualized using decision trees.

Results

In the adult blended case study, online questionnaires detected STBs and triggered automated support information. As on-site therapy had already ended, a telephone consultation session allowed for the identification and discussion of the heightened intensity of suicidal thoughts, along with the development of specific additional help options. In the youth standalone case study, heightened tension in an adolescent with PTSD during trauma processing could be addressed in a telephone therapeutic session focusing on resource activation and emotion regulation. The referral to on-site treatment was supported. Overall, advantages of the NE management included automated procedures, multimodal assessment of a wide range of NEs, and standardized procedures tailored to different severity levels. Weaknesses included the use of single-item assessments for STBs and lack of procedures in case of deterioration or nonresponse to treatment.

Conclusion

This study provides practical insights and derives key learnings and recommendations regarding the management of NEs in different IMI contexts for both adults and youth.

Remaining Between the Cracks - The Long-Term Effect of Different Suicide Risk Exclusion Criterion on Outcomes of an Online Intervention for Depression

Background: Previous studies have demonstrated that excluding individuals at risk of suicide from online depression interventions can impact recruited sample characteristics. Aim: To determine if a small change in suicide risk exclusion criterion led to differences in the usage and effectiveness of an Internet depression intervention at 6 months of follow-up. Method: A partial sample of a recently completed online depression intervention trial was divided into two groups: those with no risk of suicide versus those with some risk. The two groups were compared for baseline demographic and clinical measures, as well as intervention uptake and treatment success across 6 months. Results: Overall, individuals with less risk of suicide at baseline reported significantly less severe clinical symptoms. Both groups interacted with the intervention at the same rate, but specific use of modules was different. Finally, the impact of intervention usage on outcomes over time did not vary by group. Limitations: While different suicide risk exclusion criteria can change recruited sample characteristics, it remains unclear how these differences impact intervention uptake and success. Conclusion: Overall, the findings suggest that researchers should exercise caution when excluding individuals at risk of suicide, as they greatly benefit from web-based interventions.

Monitoring and responding to signals of suicidal ideation in pragmatic clinical trials: Lessons from the GRACE trial for Chronic Sickle Cell Disease Pain

Sickle cell disease (SCD) is a hemoglobin disorder and the most common genetic disorder that affects 100,000 Americans and millions worldwide. Adults living with SCD have pain so severe that it often requires opioids to keep it in control. Depression is a major global public health concern associated with an increased risk in chronic medical disorders, including in adults living with sickle cell disease (SCD). A strong relationship exists between suicidal ideation, suicide attempts, and depression. Researchers enrolling adults living with SCD in pragmatic clinical trials are obligated to design their methods to deliberately monitor and respond to symptoms related to depression and suicidal ideation. This will offer increased protection for their participants and help clinical investigators meet their fiduciary duties. This article presents a review of this sociotechnical milieu that highlights, analyzes, and offers recommendations to address ethical considerations in the development of protocols, procedures, and monitoring activities related to suicidality in depressed patients in a pragmatic clinical trial.

Preliminary Effectiveness of a Therapist-Supported Digital Mental Health Intervention in Reducing Suicidal Ideation

Suicidal ideation (SI) is a significant public health concern with increasing prevalence. Therapist-supported digital mental health interventions (DMHI) are an emergent modality to address common mental health problems like depression and anxiety, although less is known about SI. This study examined SI trajectories among 778 patients who participated in a therapist-supported DMHI using multilevel models during and up to 6-months post-treatment. Estimates of associated suicide attempts and deaths by suicide were calculated using published data linking PHQ-9-assessed SI to records of suicide attempts and deaths by suicide. The proportion of participants reporting no SI significantly increased between baseline and end-of-treatment (78.02% to 91.00%). Effect sizes of SI changes between baseline and end-of-treatment, 3-month, and 6-month follow-ups were 0.33 (95%CI = 0.27-0.38), 0.32 (95%CI = 0.27-0.38), and 0.32 (95%CI = 0.27-0.38), respectively. Results also indicated an estimated 30.49% reduction (95%CI = 25.15%-35.13%) in suicide attempts and death by suicide across treatment. This study provides preliminary evidence of the effectiveness of a therapist-supported DMHI in reducing SI.

Effects of digital cognitive behavioral therapy for depression on suicidal thoughts and behavior: Protocol for a systematic review and meta-analysis of individual participant data

INTRODUCTION

Digital cognitive behavioral therapy (i-CBT) interventions for the treatment of depression have been extensively studied and shown to be effective in the reduction of depressive symptoms. However, little is known about their effects on suicidal thoughts and behaviors (STB). Information on the impact of digital interventions on STB are essential for patients' safety because most digital interventions are self-help interventions without direct support options in case of a suicidal crisis. Therefore, we aim to conduct a meta-analysis of individual participant data (IPDMA) to investigate the effects of i-CBT interventions for depression on STB and to explore potential effect moderators.

METHODS

Data will be retrieved from an established and annually updated IPD database of randomized controlled trials investigating the effectiveness of i-CBT interventions for depression in adults and adolescents. We will conduct a one-stage and a two-stage IPDMA on the effects of these interventions on STB. All types of control conditions are eligible. STB can be measured using specific scales (e.g., Beck scale suicide, BSS) or single items from depression scales (e.g., item 9 of the PHQ-9) or standardized clinical interviews. Multilevel linear regression will be used for specific scales, and multilevel logistic regression will be used for treatment response or deterioration, operationalized as a change in score by at least one quartile from baseline. Exploratory moderator analyses will be conducted at participant, study, and intervention level. Two independent reviewers will assess the risk of bias using the Cochrane Risk of Bias Tool 2.

CONCLUSION

This IPDMA will harness the available data to assess the effects (response and deterioration) of i-CBT interventions for depression interventions on STB. Information about changes in STB is essential to estimate patients' safety when engaging in digital treatment formats.

TRIAL REGISTRATION

We will pre-register this study with the open science framework after article acceptance to ensure consistency between online registration and the published trial protocol.

Artificial intelligence-informed mobile mental health apps for young people: a mixed-methods approach on users' and stakeholders' perspectives

BACKGROUND

Novel approaches in mobile mental health (mHealth) apps that make use of Artificial Intelligence (AI), Ecological Momentary Assessments, and Ecological Momentary Interventions have the potential to support young people in the achievement of mental health and wellbeing goals. However, little is known on the perspectives of young people and mental health experts on this rapidly advancing technology. This study aims to investigate the subjective needs, attitudes, and preferences of key stakeholders towards an AI-informed mHealth app, including young people and experts on mHealth promotion and prevention in youth.

METHODS

We used a convergent parallel mixed-method study design. Two semi-structured online focus groups (n = 8) and expert interviews (n = 5) to explore users and stakeholders perspectives were conducted. Furthermore a representative online survey was completed by young people (n = 666) to investigate attitudes, current use and preferences towards apps for mental health promotion and prevention.

RESULTS

Survey results show that more than two-thirds of young people have experience with mHealth apps, and 60% make regular use of 1-2 apps. A minority (17%) reported to feel negative about the application of AI in general, and 19% were negative about the embedding of AI in mHealth apps. This is in line with qualitative findings, where young people displayed rather positive attitudes towards AI and its integration into mHealth apps. Participants reported pragmatic attitudes towards data sharing and safety practices, implying openness to share data if it adds value for users and if the data request is not too intimate, however demanded transparency of data usage and control over personalization. Experts perceived AI-informed mHealth apps as a complementary solution to on-site delivered interventions in future health promotion among young people. Experts emphasized opportunities in regard with low-threshold access through the use of smartphones, and the chance to reach young people in risk situations.

CONCLUSIONS

The findings of this exploratory study highlight the importance of further participatory development of training components prior to implementation of a digital mHealth training in routine practice of mental health promotion and prevention. Our results may help to guide developments based on stakeholders' first recommendations for an AI-informed mHealth app.

In Case of an Emergency: The Development and Effects of a Digital Intervention for Coping With Distress in Norway During the COVID-19 Pandemic

Background: The COVID-19 pandemic and its consequences has been found to negatively affect the general population's psychological well-being. Objective: The objectives of this paper are to report on the development and clinical effects of a self-guided Internet-delivered intervention for adults in Norway who suffer from mild to moderate psychological distress during the COVID-19 pandemic. Methods: The participants, recruited between April and December 2020, were randomized to receive a new treatment module either every third or every fifth day. The clinical outcomes were self-reported depressive and anxiety symptoms and change in positive and negative emotions. Results: A total of 1256 individuals accessed the pre-screening survey, 407 were eligible and 92 provided contact information, where 82 were included in the study, n = 44 in the 3-day group and n = 38 in the 5-day group. Overall, the statistical analyses showed a significant decrease in depressive and anxiety symptoms and an increase in positive emotions, with small and moderate within group effect sizes. No significant differences between the groups were identified in clinical outcomes or adherence. Conclusion: These findings indicate that psychological distress in the general population during the COVID-19 pandemic may be reduced through the use of a scalable self-guided Internet-delivered intervention. Furthermore, the lack of significant differences between the 5-day and 3-day group may indicate that the intervention can be delivered at a more intensive pace without negatively affecting treatment outcomes. The results need to be interpreted with caution as the sample was self-selected, as well as the lack of passive control group. Hence the results may be attributed to external factors.

Falling between the cracks: The effect of using different levels of suicide risk exclusion criteria on sample characteristics when recruiting for an online intervention for depression

BACKGROUND

Despite a strong link between suicide risk and depression, a recent literature review found that many effectiveness studies for online depression interventions exclude individuals at risk of suicide. This study scrutinizes how different suicide risk exclusion criteria impact recruitment rates and final sample characteristics.

MATERIALS AND METHODS

Two recruitment periods for an online depression intervention trial utilized different suicide risk cutoff exclusion criteria, a one-point difference on the last item of the Personal Health Questionnaire (i.e., more than 0 (Not at all) vs. more than 1 (Several Days)). Bivariate statistics were used to assess differences in recruitment rates and sample characteristics between these two recruitment periods, while all other eligibility criteria and recruitment strategies remained consistent.

RESULTS

The recruitment period using the least restrictive suicide risk exclusion criteria yielded twice as many participants; however, recruited sample characteristics did not significantly differ among demographic or clinical characteristics, despite observable trends.

DISCUSSION

Researchers should carefully select suicide risk exclusion criteria that balance recruitment rates, study budgets, and sample selection biases, while minimizing participant harm. Moreover, researchers are urged to report suicide risk exclusion rates and consider these exclusions when interpreting results. Limitations of the results are also discussed.

Ethical issues and practical barriers in internet-based suicide prevention research: a review and investigator survey

BACKGROUND

People who are at elevated risk of suicide stand to benefit from internet-based interventions; however, research in this area is likely impacted by a range of ethical and practical challenges. The aim of this study was to examine the ethical issues and practical barriers associated with clinical studies of internet-based interventions for suicide prevention.

METHOD

This was a mixed-methods study involving two phases. First, a systematic search was conducted to identify studies evaluating internet-based interventions for people at risk of suicide, and information pertaining to safety protocols and exclusion criteria was extracted. Second, investigators on the included studies were invited to complete an online survey comprising open-ended and forced-choice responses. Quantitative and qualitative methods were used to analyse the data.

RESULTS

The literature search identified 18 eligible studies, of which three excluded participants based on severity of suicide risk. Half of the 15 suicide researchers who participated in the survey had experienced problems obtaining ethics approval, and none had encountered adverse events attributed to their intervention. Survey respondents noted the difficulty of managing risk in online environments and the limitations associated with implementing safety protocols, although some also reported increased confidence resulting from the ethical review process. Respondents recommended researchers pursue a collaborative relationship with their research ethics committees.

CONCLUSION

There is a balance to be achieved between the need to minimise the risk of adverse events whilst also ensuring interventions are being validated on populations who may be most likely to use and benefit from them (i.e., those who prefer anonymity). Further research is required to obtain the views of research ethics committees and research participants on these issues. Dialogue between researchers and ethics committees is necessary to address the need to ensure safety while also advancing the timely development of effective interventions in this critical area.

Developing a Suicide Prevention Social Media Campaign With Young People (The #Chatsafe Project): Co-Design Approach

BACKGROUND

Young people commonly use social media platforms to communicate about suicide. Although research indicates that this communication may be helpful, the potential for harm still exists. To facilitate safe communication about suicide on social media, we developed the #chatsafe guidelines, which we sought to implement via a national social media campaign in Australia. Population-wide suicide prevention campaigns have been shown to improve knowledge, awareness, and attitudes toward suicide. However, suicide prevention campaigns will be ineffective if they do not reach and resonate with their target audience. Co-designing suicide prevention campaigns with young people can increase the engagement and usefulness of these youth interventions.

OBJECTIVE

This study aimed to document key elements of the co-design process; to evaluate young people's experiences of the co-design process; and to capture young people's recommendations for the #chatsafe suicide prevention social media campaign.

METHODS

In total, 11 co-design workshops were conducted, with a total of 134 young people aged between 17 and 25 years. The workshops employed commonly used co-design strategies; however, modifications were made to create a safe and comfortable environment, given the population and complexity and sensitivity of the subject matter. Young people's experiences of the workshops were evaluated through a short survey at the end of each workshop. Recommendations for the campaign strategy were captured through a thematic analysis of the postworkshop discussions with facilitators.

RESULTS

The majority of young people reported that the workshops were both safe (116/131, 88.5%) and enjoyable (126/131, 96.2%). They reported feeling better equipped to communicate safely about suicide on the web and feeling better able to identify and support others who may be at risk of suicide. Key recommendations for the campaign strategy were that young people wanted to see bite-sized sections of the guidelines come to life via shareable content such as short videos, animations, photographs, and images. They wanted to feel visible in campaign materials and wanted all materials to be fully inclusive and linked to resources and support services.

CONCLUSIONS

This is the first study internationally to co-design a suicide prevention social media campaign in partnership with young people. The study demonstrates that it is feasible to safely engage young people in co-designing a suicide prevention intervention and that this process produces recommendations, which can usefully inform suicide prevention campaigns aimed at youth. The fact that young people felt better able to safely communicate about suicide on the web as a result of participation in the study augurs well for youth engagement with the national campaign, which was rolled out across Australia. If effective, the campaign has the potential to better prepare many young people to communicate safely about suicide on the web.

An Enhanced Social Networking Intervention for Young People with Active Suicidal Ideation: Safety, Feasibility and Acceptability Outcomes

Online social networking interventions have potential to support young people who experience suicidal thoughts by specifically addressing interpersonal risk factors for suicide, but may also pose a risk of harm. This uncontrolled, single-group pilot study aimed to evaluate the safety, feasibility, and acceptability of an enhanced online social networking intervention ("Affinity") among a sample of young people who experienced active suicidal ideation, and to explore potential changes in clinical outcomes and the therapeutic targets of the intervention. Twenty young people with current or recent suicidal ideation who were receiving treatment for depression at a tertiary-level mental health service were given access to Affinity for two months. Participants were assessed at baseline and 8-week follow-up; 90 percent reported clinical suicidal ideation at baseline. A priori criteria related to feasibility, safety and acceptability were satisfied. In terms of potential clinical effects, significant and reliable pre-post improvements were found on self-report outcomes including suicidal ideation. This study provides initial world-first evidence to support the use of an online intervention incorporating social networking as an adjunct to treatment for young people who experience suicidal ideation. The effectiveness of Affinity needs to be evaluated in a randomised controlled trial.

Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression: Randomized Controlled Trial

Background

Adolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments.

Objective

This trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents.

Methods

The trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment.

Results

IPDT was significantly more effective than the control condition in reducing depression (d=0.82, P=.01), the result of which was corroborated by the second depression measure (d=0.80, P<.001). IPDT was also significantly more effective in reducing anxiety (d=0.78, P<.001) and increasing emotion regulation (d=0.97, P<.001) and self-compassion (d=0.65, P=.003). Significantly more patients in the IPDT group compared to the control group met criteria for response (56% vs 21%, respectively) and remission (35% vs 8%, respectively). Results on depression and anxiety symptoms were stable at 6 months follow-up. On average, participants completed 5.8 (SD 2.4) of the 8 modules.

Conclusions

IPDT may be an effective intervention to reduce adolescent depression. Further research is needed, including comparisons with other treatments.

Trial Registration

International Standard Randomised Controlled Trial Number (ISRCTN) 16206254; http://www.isrctn.com/ISRCTN16206254

Digital Mental Health and COVID-19: Using Technology Today to Accelerate the Curve on Access and Quality Tomorrow

As interest in and use of telehealth during the COVID-19 global pandemic increase, the potential of digital health to increase access and quality of mental health is becoming clear. Although the world today must "flatten the curve" of spread of the virus, we argue that now is the time to "accelerate and bend the curve" on digital health. Increased investments in digital health today will yield unprecedented access to high-quality mental health care. Focusing on personal experiences and projects from our diverse authorship team, we share selected examples of digital health innovations while acknowledging that no single piece can discuss all the impressive global efforts past and present. Exploring the success of telehealth during the present crisis and how technologies like apps can soon play a larger role, we discuss the need for workforce training, high-quality evidence, and digital equity among other factors critical for bending the curve further.